BAD RESULTS OF CONSERVATIVE TREATMENT OF ACL TEARS IN CHILDREN. Guy BELLIER PARIS France

Transcription

1 BAD RESULTS OF CONSERVATIVE TREATMENT OF ACL TEARS IN CHILDREN Guy BELLIER PARIS France

2 TREATMENT OF ACL TEARS IN CHILDREN CONTROVERSIAL

3 DIAGNOSIS clinical exam X-rays (stress) M.R.I. arthroscopy

4 ACL TEARS IN CHILDREN open physis exclusion criteria ATS fractures congenital absence of ACL hyperlaxity

5 ANATOMICAL TYPE femoral or tibial avulsion complete midsubstance tear partial tear

6 ASSOCIATED LESIONS Litterature compilation : 190 ACL tears 96 meniscal lesions : 50% 14 MCL tears : 7%

7 CLINICAL EXAM, MRI, ARTHROSCOPY CORRELATION IN CHILDREN. C. Stanitski AJSM children (14 ACL tears) highly positive correlation : clinical exam-arthroscopy highly negative correlation : MRI-arthroscopy

8 MRI HIGH-SIGNAL INTENSITY IN THE MENISCI OF ASYMPTOMATIC CHILDREN Y.Takeda & al. JBJS boys and 29 girls (mean age 12.2) - 66% prevalence of high-signal intensity (adults 29%) - Prevalence decreased with skeletal maturity

9 PEDIATRIC ACL INJURIES G.Bellier 40 children (20 girls,20 boys) Mean age : 13 y.o. (9.5 to 16) Average follow-up : 3 y. (1 to 20) Exam U.A. +\- arthroscopy

10 TREATMENT 25 conservative management (cast 3 to 6 weeks) 14 sutures for proximal or distal tears 1 primary reconstruction (autograft) 11 partial meniscectomies

11 RESULTS 13/25 (52%) required intra-articular reconstruction 1 to 5 years later 10 good or excellent results (Lachman +) 3 poor or bad results (Lachman ++ or +++) 10/14 sutures stable with Lachman + 4 instability : reconstruction

12 MENISCAL LESIONS B.K.Graf Arthroscopy ALL braced patients + 2 tenodesis : developed instability (7 to 15 months) - 7 patients further meniscal damage (15 months) - 2 IA ST : no instability,lachman test +,no growth disturbance at 21 and 27 months

13 MENISCAL LESIONS G.Bellier 10 children with M.R.I. 7 medial meniscus lesions (4 secondary) 2 partial medial meniscectomies (1 failed suture) 3 medial meniscus sutures 2 : no treatment

14 NATURAL HISTORY

15 BAD RESULTS OF CONSERVATIVE TREATMENT - Kannus & Jarvinen [JBJS 1987] - Mc Carroll [AJSM 1995] - Mizuta [JBJS 1995] - Patel & Aichroft [JBJS 1993] - Bellier [ITS 1997] - Pressman [JPO 1997]

16 Engebretsen L & al: Poor results of anterior cruciate ligament repair in adolescence Acta Orthop Scand 59: , 686, adolescents, suture repair ACL F/U 3-8 years 3 good, 5 unstable -> Reconstruction probably better than suture repair

17 SURGICAL TECHNIQUES Intra-articular reconstruction with autograft Ilio-tibial band Patellar tendon Hamstrings (gracilis + semitendinosus) Quadriceps tendon (+/- bone block)

18 ACL RECONSTRUCTION WITH QUADRICEPS TENDON as strong as patellar tendon no anterior tibial tuberosity harvesting patellar periosteal flap

19 MANAGEMENT AND COMPLICATIONS OF ACL TEARS IN SKELETALLY IMMATURE PATIENTS A survey of members of the ACL Study Group (83/138) - Average age : Non-operative : 57.8% (8 yo) 49.4% (13 yo) - Immediate reconstruction : 14.5% (8 yo) 34.5% (13 yo) - Tibial technique :transphyseal (80.5%),epiphyseal (15.6%),no tunnel (3.9%) - Femoral technique : transphyseal ( 52.6%),over-the-top (47.3%) - Graft preference : hamstrings (72.1%),PT (16.5%),other ( 11.3%) - 8.4% (7/83) growth disturbance (femur 5, tibia 2)

20 ACL TEARS IN CHILDREN : AN ANALYSIS OF OPERATIVE VERSUS NON-OPERATIVE TREATMENT. A.E.PRESSMAN & coll. J.P.O tears in 40 children,retrospective - Mean follow-up : 5.3 years - KT-1000 measurements - Treatment - Non-operative : 13 - Primary repair : 6 - Reconstruction : 23 (17 PT,6 ST)

21 ACL TEARS IN CHILDREN : AN ANALYSIS OF OPERATIVE VERSUS NON-OPERATIVE TREATMENT. A.E.PRESSMAN & coll. J.P.O The ACL reconstruction group had better results in - Functionnal score - Clinical examination - KT-1000 results - No deleterious effect of leg lenght discrepancy or angular deformity by using intra-articular tunnels that violate the physis

22 GROWTH REMAINING Trauma of the cartilage of the ATT 3 years earlier RECURVATUM

23

24 ACL TEARS IN CHILDREN - ACL tears in children are not minor injuries - An overly conservative approach is not justified - Correct grafts (autologous ST,quadriceps T.) lead to good results (KT-1000,IKDC) - Careful drilling of the open physis